NCI Radiation Oncology Program Tackles Cancer Disparities
For many years, it has been known that certain U.S. populations experience a greater incidence, prevalence, mortality, and overall burden from cancer.
Such disparities are evident throughout the American health care system: People in underserved populations and communities have less awareness of cancer, which translates into less healthy behaviors, less screening, and patients presenting at later stages in the course of disease. In addition, institutions that provide the care for a disproportionate number of medically underserved people are not usually involved in NCI research - and clinicians who treat low-income, ethnic, and minority populations do not typically devise clinical trials.
One NCI response to those circumstances has been to fund six flagship studies in radiation oncology through grants from NCI's Cancer Disparities Research Partnership (CDRP) Program.
"We realized that trying to do cancer research on health disparities was a complex undertaking," says Dr. Frank Govern, deputy director of the Radiation Oncology Sciences Program. "The organizational models developed to conduct research in the mainstream population didn't fit here. We know, for example, that Hispanic males have much greater incidence and mortality of cancers of the stomach, gall bladder, and liver. Too few studies have explored why that may be so."
In the early 2000s, Dr. Govern and Dr. C. Norman Coleman, associate director of the Radiation Research Program in the Division of Cancer Treatment and Diagnosis, hoped to reverse these trends by crafting a blueprint for the CDRP based on a new model. "Rather than hoping centers and physicians in disparities regions would be reached by the cancer centers and cooperative groups, we reversed the dynamics and brought the resources to the disparities regions and empowered them to reach out to the major centers and groups," explains Dr. Govern. Through creative funding approaches to nontraditional organizational models, "We sought to take the high-tech oncology research enterprise directly to the populations and institutions where the people who most need it are not getting its benefits."
Radiation oncology provides "fertile ground for conducting disparities research," Dr. Govern adds. "CDRP is a focused effort to leverage national resources and deliver them to smaller hospitals and treatment centers - and the minority populations they treat - who often don't have access to clinical trials." Several components have been incorporated into the CDRP grant structure: a relationship with a large comprehensive cancer center as a mentor in the conduct of those clinical trials; the use of NCI's TeleSynergy® system to enhance communications; and "patient navigators" to provide one-on-one assistance to patients in the trials.
Dr. Patrick Maguire, principal investigator for one of the six projects, is a radiation oncologist at the Zimmer Cancer Center, part of the New Hanover Regional Medical Center (NHRMC) in Wilmington, N.C. "We hope to establish a presence in our community to enhance cancer awareness for patients and clinicians alike," Dr. Maguire notes. His CDRP trial recruits primarily African Americans for a study of hyperfractionated intensity modulated radiotherapy on stage III and IV-A head and neck cancers.
The nine counties served by NHRMC typify the CDRP focus on underserved populations. The counties are 22.5 percent African American, compared with 12.3 percent for the United States as a whole. Overall, North Carolina's median per capita income of $13,548 is 37 percent lower than the national average. For African Americans in the nine counties, median income is generally even less, ranging from $9,624 to $14,083. These are not the people who typically find their way to government-funded clinical trials, explains Dr. Maguire, "but we do active outreach into the community, and we partner with physicians who refer their patients for our clinical trials."
The CDRP model recasts the major U.S. cancer centers in a mentoring, supportive role. Radiation oncologists from the University of North Carolina at Chapel Hill advise and consult with Dr. Maguire and other members of the NHRMC treatment staff. Such consultation revolves around clinical research using the TeleSynergy work stations installed at both sites. Physicians several hundreds of miles apart talk with patients and with one another over joint access to medical records, CT and MRI images, and pathology specimens.
The third piece of the partnership is the Patient Navigator program. At each CRDP trial site, NCI's Center to Reduce Cancer Health Disparities provides support for one or more counselors to work with each patient, guiding them through the process, helping to navigate the obstacles they encounter, and ensuring they don't give up or drop out of continuing care. This system is the key to success, according to Tufanna Bradley, the patient navigator for the NHRMC trial. "It's easier to provide individualized support because I can usually establish a bond with patients because I go to their church, or at least I know their neighborhood," she says.
Other CRDP partnerships support trials in Inglewood, Calif.; McKeesport, Pa.; Rapid City, S.D.; Laredo, Texas; and Pascagoula, Miss., reaching other underserved populations and communities, such as Hispanic/Latinos, Native Americans, and the poor in inner-city and rural environments.
By Addison Greenwood